Violent patient Flashcards
1
Q
Differential diagnosis
A
1. Medical disorders Delirium Dementia Hypoglycemia Post-ictal Hypoxia Meningitis, head injury CVA Encephalopathy Vasculitis Meatbolic: failures, hypoN, ++Ca+, +Na, Wernickes, acute intermittent porphyria Endocrine: thyroid Sepsis Situations: post op, faecal impaction, retention 2. Substance intoxication/withdrawal/side effects Alcohol Cocaine Methamphetamine Ecstasy PCP LSD SE: analgesics, antiCon, antipsychotics, polypharmacy 3. Psychiatric disorders Schizophrenia Mania Psychotic depression Personality disorders PTSD
2
Q
Risk factors for sudden violence
A
Younger age Male Low SES History of violence Prior juvenile detention Hx physical abuse by parent/guardian Substance Comorbid psychaitric Victimisation in past year
3
Q
ABC assessment of potentially violent patient
A
1. Assessment Appearance: flushing skin, dilated pupils, shallow rapid respirations, ++perspiration Medical status Psychiatric history Current medication Oriented 2. Behavioural indications Intoxication/agitted Irritability Hostility Impulsive, rage, damage 3. Conversion Weapon, history, thoughts of harm others/self, threats, substance
4
Q
Overview steps in management
A
- Recognise warning signs, always assess suicidality
- Attend as priority, do not delay
- Ensure safety of self and others
- ++Support
- Use least invasive method
Verbal de-escalation inc offer of oral medication
Show of force
Physical restraint
Chemical restraint + post medication monitoring - Record details
- Admit if further management required
- Debrief
5
Q
De-escalation
A
- Be calm, define acceptable and unacceptable behaviours
- Allow to state concerns
- Explain role and wish to help
- Offer support- food, drinks, assistance
- Offer oral medication
Diazepam 10-20mg PO repeat after 60 mins if required
6
Q
Physical restraint
A
- Immobilise
2. Requires well trained personell
7
Q
Pharmacological management in acute medical settings
A
- Have resus available, monitor vitals
- Diazepam 5mg IV repeat every 3-4 minutes, max of 30mg OR midazolam 2.5-5mg IV every 3-4 minutes, max 30mg
- If tolerant to benzodiazepine or failure of benzo->droperidol 2.5-5mg IV / 3-4 minutes max 20mg OR (2) olanzapine 5mg IV max 20mg
- If IM prefer: midazolam 5-10mg IM OR droperidol 5-10mg OR olanzapine 10mg IM
8
Q
Pharmacological management in acute psychiatric setting
A
- diazepam 5-20mg PO, 2-6 hrly, max 120mg OR lorazepam 1-2mg PO, max 10mg
- If not achieved: ADD
Suitable dose of patients current anti-Psych medication
Olazepine 5-10mg PO, 2-4 hrly, max 30mg
Risperidone 0.5-1mg PO, max 6mg - If IM preferred: midazolam 2.5-10g IM, every 20 minutes, max 20mg
- If want tranquilisation for 2-3 days: zuclopenthixol acetate
9
Q
Post medication monitoring and management
A
- Vital signs 10-15minutely
- Airway
- Skin color
- LOC
- Ongoing behavioural disturbance
- Response to medication
10
Q
When to continue monitoring post medication
A
Need to be able to
- Mainain 02 stas >90% RA
- Have intact airway reflexes
- BP >100-120
11
Q
Main risks of medication
A
- Airway obstruction
- Respiratory depression
- Aspiration
- Profound hypotension
- Laryngospasm
12
Q
Investigations to consider
A
- Blood glucose
- FBC
- UEC
- LFTs
- Paracetamol,ethanol levels
- Urinalysis
- UDS
- ?CT head ?LP->depending on presentation
13
Q
Complications of restraining / medication
A
- Resp depression
- Cardiac depression
- Delirium
- Hypotension
- Rhabdomyolysis
- Dystonic reactions
- NMS
- Anticholinergic
- Lactic acidosis
- Lowered seizure threshold
14
Q
Indications for restraint
A
- Other methods to control the behaviour have failed such as de-escalation techniques; and
- The patient displays aggressive or combative behaviour which arises from a medical or psychiatric condition (including intoxication); and
- The patient requires urgent medical or psychiatric care; and
- The behaviour involves a proximate risk of harm to the patient or others, or risk of significant destruction of property.
